Estimation of glomerular filtration rate to prevent life-threatening hyperkalemia due to combined therapy with spironolactone and angiotensin-converting enzyme inhibition or angiotensin receptor blockade

Blaustein, Daniel A.; Babu, Krishnan; Reddy, A. Adhipathi; Schwenk, Michael H.; Avram, Morrell M.

doi:10.1016/s0002-9149(02)02580-8

Cited by 24 publications

(16 citation statements)

References 10 publications

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“…Although we could not assess the impact of the use of spironolactone on outcomes, there is evidence that use of spironolactone in elderly patients without consideration of serum potassium and creatinine values can result in adverse outcomes, including death. [7][8][9] In conclusion, the prescription of spironolactone in older patients with LSVD hospitalized with heart failure increased substantially in the United States after publication of RALES. More than one third of prescriptions were provided to patients who did not meet enrollment criteria of the trial, many of whom had characteristics that placed them at high risk for hyperkalemia.…”

Section: Masoudi Et Al Spironolactone Prescription In Heart Failurementioning

confidence: 88%

“…25 Several subsequent case series have described patients with hyperkalemia requiring hospitalization, some of whom died. [5][6][7][8][9] Many patients in these series were elderly, in whom the serum creatinine value often overestimates true renal function. The results of our study raise significant concerns about the safety of current patterns of spironolactone prescription in community-based populations, particularly among older patients with noncardiovascular comorbidities.…”

Section: Masoudi Et Al Spironolactone Prescription In Heart Failurementioning

confidence: 99%

“…Because of the potential risks of spironolactone therapy, concerns have been raised about the application of the trial results in case reports and series from single centers. [2][3][4][5][6][7][8][9] More recently, a study from Canada reported simultaneous increases in spironolactone prescriptions and hospitalizations for hyperkalemia after the publication of RALES. 10 Although that study could not determine whether that observation resulted from spironolactone use in patients at high risk for hyperkalemia in clinical practice, it suggests the possibility of inappropriate use or inadequate monitoring of spironolactone in the community.…”

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confidence: 99%

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Adoption of Spironolactone Therapy for Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction in the United States, 1998–2001

et al. 2005

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Background-Concerns have been raised about the appropriateness of spironolactone use in some patients with heart failure. We studied the adoption of spironolactone therapy after publication of the Randomized Aldactone Evaluation Study (RALES) in national cohorts of older patients hospitalized for heart failure. Methods and Results-This is a study of serial cross-sectional samples of Medicare beneficiaries Ն65 years old discharged after hospitalization for the primary diagnosis of heart failure and with left ventricular systolic dysfunction. The first sample was discharged before (April 1998 to March 1999) and the second sample after (July 2000 to June 2001, nϭ9468) publication of RALES in September 1999. We assessed spironolactone prescriptions at hospital discharge in patient groups defined by enrollment criteria for the trial. Using multivariable logistic regression, we identified factors independently associated with prescriptions not meeting these criteria. Spironolactone use increased Ͼ7-fold (3.0% to 21.3% PϽ0.0001) after RALES. Of patients meeting enrollment criteria, 24.1% received spironolactone, as compared with 17.4% of those not meeting the criteria. Of all prescriptions after RALES, 30.9% were provided to patients not meeting enrollment criteria. Spironolactone was prescribed to 22.8% of patients with a serum potassium value Ն5.0 mmol/L, to 14.1% with a serum creatinine value Ն2.5 mg/dL, and to 17.3% with severe renal dysfunction (estimated glomerular filtration rate Ͻ30 mL · min Ϫ1 · 1.73 m Ϫ2 ). In multivariable analyses, factors associated with prescriptions not meeting enrollment criteria included advanced age, noncardiovascular comorbidities, discharge to skilled nursing facilities, and care provided by physicians without board certification. Conclusions-Spironolactone prescriptions increased markedly after the publication of RALES, and many treated patients were at risk for hyperkalemia. Simultaneously, many patients who might have benefited were not treated. These findings demonstrate the importance of balancing efforts to enhance use among appropriate patients and minimizing use in patients at risk for adverse events.

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Section: Masoudi Et Al Spironolactone Prescription In Heart Failurementioning

confidence: 88%

Section: Masoudi Et Al Spironolactone Prescription In Heart Failurementioning

confidence: 99%

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confidence: 99%

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Adoption of Spironolactone Therapy for Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction in the United States, 1998–2001

et al. 2005

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“…K + supplements were used by 29% of the patients in the spironolactone group. It should be emphasized that in clinical practice following the RALES serum creatinine exclusion criteria of >2.5 mg/dL can still result in life-threatening hyperkalemia [41,42]. Moreover, spironolactone is now more broadly used without consideration of the HF class and/or ejection fraction and without optimization of background treatment with ACE inhibitors and β-blockers [43].…”

Section: Renin-angiotensin-axismentioning

confidence: 99%

Pharmacokinetics and Pharmacodynamics of Mineralocorticoid Blocking Agents and their Effects on Potassium Homeostasis

2005

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Spironolacotone and eplerenone are mineralocorticoid-blocking agents used for their ability to block both the epithelial and non-epithelial actions of aldosterone. Spironolactone is a non-selective mineralocorticoid receptor antagonist with moderate affinity for both progesterone and androgen receptors. The latter property increases the likelihood of endocrine side effects with spironolactone including loss of libido, menstrual irregularities, gynecomastia and impotence. Eplerenone is a next generation aldosterone receptor antagonist selective for aldosterone receptors alone. This lesser affinity for progesterone and androgen receptors was arrived at by replacing the 17-alpha -thioacetyl group of spironolactone with a carbomethoxy group. Eplerenone is further distinguished from spironolactone by its shorter half-life and the fact that it does not have any active metabolites. Both eplerenone and spironolactone are effective antihypertensive agents and each has been shown to improve the morbidity and mortality of heart failure. Eplerenone or spironolactone use can increase serum potassium values and occasionally results in clinically relevant hyperkalemia. This is more apt to occur with spironolactone due to the very long half-life of several of its active metabolites.

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“…Die bei symptomatischen Patienten notwendige Diuretikatherapie reduziert das Hyperkaliämierisiko unter kombinierter Gabe von Aldosteronantagonist und ACE-Hemmer. Seitdem bei Herzinsuffizienz die Spironolactongabe empfohlen wurde, sind deutlich häufiger lebensbedrohliche dialysepflichtige Hyperkaliämien zu beobachten [35,36]. Diese treten jedoch meist dann auf, wenn Kontraindikationen zur Therapie mit Aldosteronantagonisten nicht beachtet bzw.…”

Section: Kardiale Und Vaskuläre Aldosteronsynthese Und -Wirkungunclassified

Aldosteronrezeptorblockade nach akutem Myokardinfarkt mit Herzinsuffizienz

Bauersachs¹,

Ertl

2006

Med Klin

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The present review summarizes the pathophysiological basis, the experimental and clinical trials that constitute the rationale for therapy with aldosterone antagonists in patients with acute myocardial infarction and heart failure. Tips for use in clinical practice are given which allow to profit from the effective potential for mortality and morbidity reduction of aldosterone receptor blockade and to minimize the risk of serious hyperkalemia.

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Estimation of glomerular filtration rate to prevent life-threatening hyperkalemia due to combined therapy with spironolactone and angiotensin-converting enzyme inhibition or angiotensin receptor blockade

Cited by 24 publications

References 10 publications

Adoption of Spironolactone Therapy for Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction in the United States, 1998–2001

Adoption of Spironolactone Therapy for Older Patients With Heart Failure and Left Ventricular Systolic Dysfunction in the United States, 1998–2001

Pharmacokinetics and Pharmacodynamics of Mineralocorticoid Blocking Agents and their Effects on Potassium Homeostasis

Aldosteronrezeptorblockade nach akutem Myokardinfarkt mit Herzinsuffizienz

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